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The purpose of this paper is to identify the extent of actual malnutrition and its risk among cancer patients receiving radiotherapy and/or chemotherapy in the Libyan city of Benghazi.

A cross‐sectional nutritional assessment study using the patient‐generated subjective global assessment (PG‐SGA) was carried out on 200 (91 males and 109 females) cancer patients undergoing chemotherapy and/or radiotherapy.

A total of 25 per cent of the subjects were severely malnourished while 73.5 per cent were either at risk of malnutrition or suspected to be malnourished. Almost all (99.5 per cent) needed some degree of intervention (critical in nature for 83.5 per cent). Family income and physical activity were associated with nutritional status (p<0.05). Body Mass Index alone is an insensitive criterion for identifying malnutrition among such patients. All the sections and subsections of the PG‐SGA had a statistically significant positively correlation with its total score (r=0.51‐0.96, p<0.05). Dieticians played a very limited role in patient nutritional care.

It is suggested that dieticians should play a more participatory and prominent role in a multidisciplinary team involved in patient nutritional care. The PG‐SGA can help identify areas where tailor made strategies to counteract specific malnutrition or its risk can be planned, implemented and monitored.

There exists a considerable prevalence of malnutrition among Benghazi cancer patients undergoing chemotherapy and/or radiotherapy, most of whom need critical intervention.

Treatment delays must be avoided, especially in oncology, to assure sustainable high-quality health care and increase the odds of survival. The purpose of this paper is to hypothesize that waiting times would decrease and patients and employees would benefit, when specific lean interventions are incorporated in an organizational improvement approach.

In 2013, 15 lean interventions were initiated to improve flow in a single radiotherapy institute. Process/waiting times, patient satisfaction, safety, employee satisfaction, and absenteeism were evaluated using a mixed methods methodology (2010-2014). Data from databases, surveys, and interviews were analyzed by time series analysis, χ², multi-level regression, and t-tests.

Median waiting/process times improved from 20.2 days in 2012 to 16.3 days in 2014 (p<0.001). The percentage of palliative patients for which waiting times had exceeded Dutch national norms (ten days) improved from 35 (six months in 2012: pre-intervention) to 16 percent (six months in 2013-2014: post-intervention; p<0.01), and the percentage exceeding national objectives (seven days) from 22 to 17 percent (p=0.44). For curative patients, exceeding of norms (28 days) improved from 17 (2012) to 8 percent (2013-2014: p=0.05), and for the objectives (21 days) from 18 to 10 percent (p<0.01). Reported safety incidents decreased 47 percent from 2009 to 2014, whereas safety culture, awareness, and intention to solve problems improved. Employee satisfaction improved slightly, and absenteeism decreased from 4.6 (2010) to 2.7 percent (2014; p<0.001).

Combining specific lean interventions with an organizational improvement approach improved waiting times, patient safety, employee satisfaction, and absenteeism on the short term. Continuing evaluation of effects should study the improvements sustainability.

Globally, women suffer from a lack of knowledge about breast cancer (BC), its symptoms and treatment. The purpose of this paper is to examine how people living in rural and less developed areas in Pakistan perceive BC. The study investigates the level of knowledge about BC in rural communities and analyses how the prevalent perceptions and beliefs impact women's lives and delay the diagnosis.

This study is based on 42 in-depth interviews with the women who have undergone BC treatment during the past five years. The participants were interviewed were the residents of the northern Sindh, southern Pakistan.

Findings show that BC was perceived as a contagious disease transmitted through touching or being physically close to the patient. Some women were abandoned by their husbands because of this perception. Faith in fatalism and the perception that BC is an incurable disease were common in communities with low socio-economic status. This is likely to affect the prevention and early detection of BC.

The study shows a strong co-relation of awareness with the prevalent perceptions regarding BC. Therefore, we recommend promoting health literacy and introducing culturally specific interventions in remote communities to enhance their understanding of the available treatment and help remove misconceptions about BC.

The purpose of this paper is to evaluate and improve the quality and the reliability of pre‐treatment quality controls of an efficient technique of radiotherapy called IMRT (intensity‐modulated radiation therapy). The aim is then to determine if the controls can be safely reduced while keeping an optimal level of quality.

The statistical process control method (SPC) was applied to quality assurance in IMRT. In order to characterize prostate and head‐and‐neck treatment process variability, individual value control charts and moving‐range control charts were established.

Control charts showed that prostate and head‐and‐neck treatment processes are only subject to random causes of variability, which means they are statistically controlled. It was proved that both processes are statistically stable and capable.

The paper shows that SPC is an efficient method to objectively determine if quality controls can be reduced.

Due to increasing complexity, modern radiotherapy techniques require comprehensive quality assurance (QA) programmes, that to date generally focus on the pre-treatment stage. The purpose of this paper is to provide a method for an individual patient treatment QA evaluation and identification of a “quality gap” for continuous quality improvement.

A statistical process control (SPC) was applied to evaluate treatment delivery using in vivo electronic portal imaging device (EPID) dosimetry. A moving range control chart was constructed to monitor the individual patient treatment performance based on a control limit generated from initial data of 90 intensity-modulated radiotherapy (IMRT) and ten volumetric-modulated arc therapy (VMAT) patient deliveries. A process capability index was used to evaluate the continuing treatment quality based on three quality classes: treatment type-specific, treatment linac-specific, and body site-specific.

The determined control limits were 62.5 and 70.0 per cent of the χ pass-rate for IMRT and VMAT deliveries, respectively. In total, 14 patients were selected for a pilot study the results of which showed that about 1 per cent of all treatments contained errors relating to unexpected anatomical changes between treatment fractions. Both rectum and pelvis cancer treatments demonstrated process capability indices were less than 1, indicating the potential for quality improvement and hence may benefit from further assessment.

The study relied on the application of in vivo EPID dosimetry for patients treated at the specific centre. Sampling patients for generating the control limits were limited to 100 patients. Whilst the quantitative results are specific to the clinical techniques and equipment used, the described method is generally applicable to IMRT and VMAT treatment QA. Whilst more work is required to determine the level of clinical significance, the authors have demonstrated the capability of the method for both treatment specific QA and continuing quality improvement.

The proposed method is a valuable tool for assessing the accuracy of treatment delivery whilst also improving treatment quality and patient safety.

Assessing in vivo EPID dosimetry with SPC can be used to improve the quality of radiation treatment for cancer patients.

The purpose of this paper is to describe a methodology to deal with conformance checking through the implementation of computer-interpretable-clinical guidelines (CIGs), and present an application of the methodology to real-world data and a clinical pathway for radiotherapy-related oncological treatment.

This methodology is implemented by a software able to use the hospital electronic health record data to assess the adherence of the actual executed clinical processes to a clinical pathway, monitoring at the same time management-related efficiency and performance parameters, and ideally, suggesting ways to improve them.

Three use cases are presented, in which the results of conformance checking are used to compare different branches of the executed guidelines with respect to the adherence to ideal process, temporal distribution of state-to-state transitions, and overall treatment efficacy, in order to extract data-driven evidence that could be of interest for the hospital management.

This approach has the result of applying management-oriented data mining technique on sequential data, typical of process mining, to the result of a conformity check between the preliminary knowledge defined by clinicians and the real-world data, typical of CIGs.

The subject areas are strategy, general management, health-care management, change management and inclusive growth model and application of technology to manage health care.

The case can be used to teach challenges in managing change in a health-care facility.

Tata Memorial Centre (TMC) is dedicated to provide best health-care services in the field of cancer cure. TMC established its credentials for service, education and research, which contributed to it being rated among the ten best hospitals year on year. Starting from humble moorings, TMC has grown to an institution of high repute from an 80-bed hospital to a 700-bed hospital. TMC held a number of pioneering efforts, which included bone marrow transplantation, external beam radiotherapy (linear accelerator), tumor tissue bank and bio-imaging to name a few. The management team of TMC had ensured that the growth had been orderly and appropriate to the changing needs of the community. Managing a hospital with disparate skill sets in the face of ever-increasing demand for services had always been a challenge in itself. As a government-run facility and well funded by the trust, TMC offered excellent services and post-operative care to the patients. So, it became imperative for the hospital to adopt technology to improve its hospital services and maintain transparency. Patients came to the hospital from different states in India and across the globe. TMC registered international and national patients online. Online medical reports were checked before the patients visited the hospital. TMC has developed an e-system that will allow patients around the world to send their tissue samples that are suspected to be cancerous for medical advice to the hospital. This case study is developed to provide insights into the transformation of TMC into an e-health-care service and explains the process of change management.

They are to provide insights into the challenges in health-care management, to illustrate the challenges faced by organization in implementing information and communication technology- managing change and to bring about best practices in the case organization and find solutions to the following questions: What are challenges faced by health-care officials in providing health care using new technological innovations? How can hospitals equip themselves with new technology? With the advent of improved and modern communication methods, medical practices and cases are more easily shared. Cases are discussed, recorded and, in many cases, put up for general public viewing through the electronic media. How can hospitals manage change? How can hospital administrators manage speed of delivery, quality healthcare, innovation and brand image?

Teaching notes are available for educators only. Please contact your library to gain login details or email support@emeraldinsight.com to request teaching notes.

CSS:11 Strategy.

Learning outcomes are as follows: students will discover the importance of process orientation in management; students will determine the root cause of the problem by applying root cause analysis technique; students will identify the failure modes, analyze their effect, score them on a scale and prioritize the corrective action to prevent the failures; students will analyze the processes and propose error-proof system/s; and students will analyze organizational culture and ethical issues.

Purpose: This case study is intended as a class-exercise, for students to discover the importance of process-orientation in management, analyze the ethical dilemma in health care and to apply quality management techniques, such as five-why, root cause analysis, failure mode and effect analysis (FMEA) and error-proofing, in the management of the health-care and service industry. Design/methodology/approach: A voluntary reporting of a case of “radiation overdose” in a hospital’s radio therapy treatment unit, which led to an ethical dilemma. Consequently, a study was conducted to establish the causes of the incident and to develop a fail-proof system, to avoid recurrence. Findings: After careful analysis of the process-flow and the root causes, 25 potential failure modes were detected and the team had assigned a risk priority number (RPN) for each potential incident, selected the top ten RPNs and developed an error-proofing system to prevent recurrence. Subsequently, the improvement process was carried out for all the 25 potential incidents and a new control mechanism was implemented. The question of ethical dilemma remained unresolved. Research limitations/implications: Ishikawa diagram, FMEA and Poka-Yoke techniques require a multi-disciplinary team with process knowledge in identifying the possible root causes for errors, potential risks and also the possible error-proofing method/s. Besides, these techniques need frank discussions and agreement among team members on the efforts for the development of action plan, implementation and control of the new processes. Practical implications: Students can take the case data to identify root cause analysis and the RPN (RPN = possibility of detection × probability of occurrence × severity), to redesign the protocols, through systematic identification of the deficiencies of the existing protocols. Further, they can recommend quality improvement projects. Faculty can navigate the case session orientation, emphasizing quality management or ethical practices, depending on the course for which the case is selected.

MBA or PG Diploma in Management – health-care management, hospital administration, operations management, services operations, total quality management (TQM) and ethics.

Teaching Notes are available for educators only.

CSS 9: Operations and Logistics.

Salicylate intake and lifestyle have been implicated in the aetiology of prostate cancer, but the purpose of this paper is to evaluate their influence on established cancer progression.

A randomised, double blind, phase II study involving 110 men whose prostate specific antigen (PSA), had risen in three consecutive values, >20 per cent over the proceeding six months. Men were counselled to eat less saturated fat, processed food, more fruit, vegetables and legumes; exercise more regularly and to stop smoking. They were then randomised to take sodium salicylate (SS) alone or SS combined with, vitamin C, copper and manganese gluconates (CV247). Patients took this daily, without other intervention, but were withdrawn if their PSA doubling time (PSAdt) shortened or their PSA rose >20 per cent from baseline.

Although there was no difference in outcome between the SS or CV247 (21 v 19 p = 0.92), the intervention slowed or stopped the rate of PSA progression in 40 patients (36.4 per cent) for over one year. A further ten patients were stabilised for ten months. Patients least likely to stabilise had received previous radiotherapy or had a Gleason ≥7. These men welcomed this addition to active surveillance.

A further RCT in the sensitive subgroup, would determine the role adding SS to lifestyle counselling alone. These data suggest that this intervention would be welcomed by patients as if substantiated, it could potentially delay the need for more radical therapy and their associated toxicities